Sex and Race Differences in HDL-C in Patients with Acute Coronary Syndrome

This retrospective study analyzed HDL-C levels and their associations with outcomes in 614 patients undergoing PCI for acute coronary syndrome, stratifying by sex and self-reported race/ethnicity.

Women had higher mean HDL-C levels than men across all race/ethnic groups, consistent with known sex differences in HDL metabolism. However, the protective effect of HDL-C appeared attenuated in women with ACS compared with the background population, suggesting that the traditional HDL-C threshold for “low” risk may need recalibration for women — particularly those who have already manifested ACS despite relatively normal HDL-C.

Race-related differences in HDL-C and its association with events were present but heterogeneous. The small sample size limited the ability to draw reliable subgroup conclusions within race/sex combinations.

The study contributes to the growing recognition that HDL-C is not a simple protective biomarker — its relationship to risk is modified by sex, metabolic context, and HDL function in ways that concentration alone does not capture. In the post-ACS setting, HDL-C level has limited therapeutic utility given the failure of HDL-raising agents (niacin, CETP inhibitors) to reduce events.

We rate the evidence limited. A small retrospective analysis examining sex and race variation in HDL-C patterns post-ACS — descriptive data with important limitations for clinical application.